Three-dimensional virtual reconstruction combined with the S.T.O.N.E. score improves outcomes of PCNL: a multicenter study

Objective To evaluate the impact of three-dimensional visualization virtual reconstruction (3D-VR) combined with the S.T.O.N.E. score on the efficacy of percutaneous nephrolithotomy (PCNL). Methods A prospective cohort study enrolled patients with kidney stones from six centers between July 2022 and July 2025. Participants were divided into a conventional ultrasound-guided control group and a 3D-VR group based on the surgical strategy selected by patients after informed consent. The latter group was further subdivided into a Simple 3D-VR group and a 3D-VR-Template group. Each group was further categorized into low-to-moderate risk (S.T.O.N.E. score ≤ 9) and high-risk (S.T.O.N.E. score > 9) subgroups. Perioperative indicators were compared, and the relationship between scores and stone-free rates was analyzed using logistic regression. Stratified multivariable logistic regression analyses were performed to compare 3D-VR techniques against the conventional ultrasound-guided control group across risk-based subgroups ( P < 0.05). Results No baseline differences were observed among the three groups. Compared with the conventional ultrasound-guided control group, the Simple 3D-VR group alone demonstrated reduced intraoperative blood loss, shorter nephroscopic access establishment time, and shorter hospital stay ( P < 0.05). The 3D-VR-Template group showed further reductions in these indicators and a significantly higher stone-free rate ( P < 0.05). No statistically significant differences existed between the two 3D technology groups. S.T.O.N.E. score > 9 was an independent risk factor for low stone-free rate (OR = 2.31, 95%CI: 1.12–4.76, P = 0.02). Stratified analysis revealed that while the Simple 3D-VR technique doubled stone-free rate in low-to-moderate risk patients (OR = 2.07, 95%CI: 1.04–4.03, P = 0.039), the 3D-VR-Template technology provided a superior fourfold advantage (OR = 4.15, 95%CI: 1.07–6.14, P = 0.040) specifically in high-risk cases. Conclusion Combining 3D-VR with S.T.O.N.E. scoring may optimize PCNL surgical planning, reduce intraoperative bleeding and shorten hospital stay, and may improve stone-free rate especially in patients with high-risk complex stones. Further well-designed controlled studies are warranted to confirm its clinical value.